HomeMy WebLinkAboutPermit Backflow Test 1995-7-25
-..
.~,.
SPRINGFIELD
BACKF~OW P~~VENTION D~VICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING ,SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION: 'R I d- f Y'-€ S C ~it .
. ASSESSORS MAP #: r7/-) ) '?, 4 /1-
OWNER: [(}.,(,V'\.i 'i- r11~u'V~~ (,J'f!~vr
ADDRESS: ,\," I L'\J P -re <:] c.o t!-
CITY: S{fYl' "Jf ;efc( STATE:
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
TAX LOT #: /5/C70
PHONE #:
CJL
ZIP:
--
CONTRACTOR: kfJUC::14 L,4 JVI?'\ [ ~,,>S
ADDRESS: d, \'1, X' \).0 vo 'I ~ T
PHONE #:
CITY: L lA J .e-v.. e-: !J
CONSTRUCTION CONTRACTORS REGISTRATION #:
STATE: c17L
')7gQ
ZIP: 9 N'~
EXPIRES: jO!3fJ9S
.,. "
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. '
~~.It(~1v-
SIGNATURE t
\..
7 ~J-'f; ~ ? 5
DATE
FOR OfFICE USE
----------------------------------------------------~---------------------------
DATE OF APPLICATION: 7 h 6/5- J-
RECEIPT 1I: /_~5'~g '( hSUED BY:
TOTAL AMOUNT COLLECTED: /~ '20
.
_// JOB 1I: 95/2 >('1)
//~
(
--------------------------------------------------------------------------------